Patient safety events reported in general practice: a taxonomy

Abstract

Patients give many reasons for why they have not kept up with their resolutions; research shows that many of these causal attributions are wrong. This article provides a tool to help patients sort out causes of and constraints on their behavior, in general, and exercise, in particular. Patient's diary data can be analyzed to flag erroneous causal attributions, and thus assist patients to understand their behavior. To start the diary, the clinician works with the patient to assemble a list of possible causes. Using the list, a diary is organized that tracks the occurrences of various causes and the target behavior. At the end of 2 to 3 weeks, the diary data is analyzed using conditional probability models, causal Bayesian networks or logistic regression. A key issue in the analysis of diary data is to separate out the effect of various causes. Typically, causes co-occur, making it difficult to understand their independent effects. Another problem with analysis of diary data is the small size of the data. This article shows how small longitudinal data from patient diaries can be analyzed. The analysis may refute or support causes hypothesized by the client. The patient uses the insights gained from the diary analysis to prevent relapse to unhealthy behaviors. The process is continued for several cycles of organizing, keeping, and analyzing the diary data. In each cycle, the patient gains new insights and makes additional attempts to create a positive environment that allows him or her to succeed even if his or her motivation waivers. This article provides details of how diary data can be analyzed to help patients make correct causal attributions.

Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice

“…A kappa of > 0.7 was sought and is consistent with previous studies of a similar nature. 66 The reviewers met to discuss discordant reports and where discrepancies could not be resolved by discussion between reviewers, third-person arbitration was sought from a senior investigator (ACS). 78 Learning from discussions about discordance was shared at weekly coding meetings and informed the inductive amendment of codes and their definitions throughout the study process.…”

“…[46][47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62] Several patient safety classifications were reviewed and considered for inclusion, 20,[63][64][65][66] including those developed for general practice. 7,65,[67][68][69][70] These classification systems provided considerable guidance for shaping the scope of the system needed; however, we did not judge that they would support detailed coding of patient safety incidents from general practice.…”

Assessing the patient safety culture and ward error reporting in public sector hospitals of Pakistan

“…Studies from developed nations re-affirm that a high incidence of errors can occur in the following wards due to (i) Emergency and Critical Care Units-due to high stress, fatigue, and long working hours for practitioners [43,44], (ii) Gynecology and Maternity wards-due to stress of delivering child safely, unexpected delivery complications, and dealing with anxious mothers and family attendants [45,46], (iii) General Medicine wards-due to lack of time, specialist knowledge and over-confidence [47,48], (iv) Cardiology wards-due to technical errors and misdiagnosis of medicine [49,50], (v) Surgery wards-due to technical malfunctions, anesthesia administration and wound infections [51], (vi) Nephrology wards-due to errors of prediction and errors in sampling [52,53] and (vii) Orthopedics wards--due to wrong-site surgery and medication errors [54,55].…”

Development of a master’s student assignment to promote safety and quality improvement in ambulatory settings

“…Root cause analysis can be a powerful tool in identifying potential error in the ambulatory setting. Consequently, the importance of teaching this skill to advanced practice nursing students is supported by the student's ability to identify processes that could lead to significant error potential in the ambulatory setting [7][8][9][10][11] .…”

“…Therefore, faculty decided this revised assignment should emphasize application of root cause analysis principles to identity potential errors in ambulatory settings. As fewer efforts have been directed toward addressing errors in ambulatory care than in hospitals, this assignment would provide an opportunity for students to identify potential errors in this setting [7][8][9][10][11] .…”